Victims of conscience e-survey

E-Survey

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Victim Worksheet

Purpose of E-Survey

Instructions for completion of survey

Confidentiality

General Report Part I
- Concerns about confidentiality
- Direction for disclosure
- Complainant name and address

General Report Part II
- Date and location of incident
- Nature of activity to which objection taken
- Nature of conscientious objection
- Position held by complainant
- Summary of incident

General Report Part III
- Complainant reaction (grievance, human rights, civil action)
- Consequences for complainant
- Expenses incurred by complainant
- Willingness to testify

PURPOSE OF E- SURVEY

To document the problems encountered by conscientious objectors.

If you are considering a grievance, human rights action or civil suit, you should also download the more extensive Victim Worksheet, which will assist you in identifying information you may need to establish your case.

INSTRUCTIONS FOR COMPLETION OF E-SURVEY

Determine how many different incidents are involved. Submit a separate survey for each incident.

CONFIDENTIALITY

Information collected will not be shared except in accordance with your directions.

You may be concerned that disclosure of information about your experience may cause problems for you. Alternatively, you may simply feel uncomfortable about disclosing information.

A place is provided at the beginning of the survey to express these concerns and give direction about the use of the information provided.

NOTE: Please contact the Administrator if this form fails

GENERAL REPORT PART I

CONCERNS about CONFIDENTIALITY

Please indicate your concerns about completing the survey and give directions for the handling of your survey.

I am concerned that disclosure of this information could adversely impact my employment, application for employment or educational programmes, or professional standing.

I do NOT believe that disclosure of this information will have adverse consequences for me.

Other

DIRECTION for DISCLOSURE

The information in this survey

must not be further disseminated without my permission.

may be disclosed only to elected political representatives who have put forward protection of conscience legislation

may be disclosed to anyone working to support or advance protection of conscience legislation

The following restrictions apply: (Here state conditions or restrictions you wish to impose)

Your name:

Your address:

Your telephone:
Area Code: Number:

Your fax:
Area Code: Number:

Your e-mail:

GENERAL REPORT PART II

Incident Date (Specify date, or between dates)

Incident Location (Specify company/institution/organization and address)

Nature of Activity to which Objection Taken

Abortion Artificial Reproduction Assisted Suicide Causing Death Contraceptive Service			Eugenic Screening Human Experimentation Inter-species Breeding Sterilization
Other (specifiy)
Counselling or referral for
Dispensing drugs or devices for

Nature of Conscientious Objection
Religious	Ethical		Moral		Philosophical
Other (specify)

Were you a student? Yes No If yes, indicate nature of coercion or discrimination below.
Statement by teacher Statement by administrator Selective discourtesy Censorship of student Assignment of practicums		Selection of essay topics Framing of lesson plans Selection of essay topics Selection of resources		Marking of papers Marking of exams Evaluation
Other (specify)

Were you an applicant? Yes No (If no, go to next section) If yes, please indicate what you were applying for.
Certification Education Programme Employment			Hospital Privileges Prof. Ass. Membership Union Membership
Other (Specify)

If you were an applicant: 1) Were you questioned about your willingness to participate in what you considered to be an objectionable activity? Yes No If yes, please explain. 2) Did you answer truthfully? Yes No 3) Was your application successful?Yes No If your application was unsuccessful, what reason was given?

If not an applicant, what was your position? 1) Had you been advised when you accepted your position that participation in the procedure in question was an expectation?Yes No 2) Had you previously indicated conscientious objections to the procedure in question?Yes No 3) Had you previously been exempted from participation? Yes No 4) Had you previously taken part in the procedure in question? Yes No 5) Did you participate in the procedure to which you objected? Yes No If so, why? Summary of Incident
GENERAL REPORT PART III
Did you file a grievance? Yes No If yes, results? If no, why not? If grievance filed, date concluded:

Did you file a human rights complaint?Yes No If yes, results? If no, why not? If human rights complaint filed, date concluded:

Did you file a civil suit? Yes No If yes, results? If no, why not? If civil suit filed, date concluded:

Employment or Educational Consequences Personal Consequences Total Expenses Incurred: Are you willing to testify to your experience at legislative committee hearings?Yes No